Chronic and Cancer Pain Care: An Introduction and Perspective

Chronic pain and cancer pain invokes many images to physicians, patients, and families. For too long, chronic pain and cancer pain have been an undertreated and neglected part of our society’s medical care delivery system. Those of us involved in pain medicine, as physicians and patients, know that these pain states are very real and often poorly managed by colleagues and patients.

Many have considered short-term approaches to pain care as the ideal, using nerve blocks to the exclusion of other therapies. Other colleagues have vigorously and actively avoided any use of regional analgesia techniques in the patient with chronic pain or cancer pain. As a physician with a practice of pain medicine spanning nearly three decades, I believe that the polar ends of this conceptual continuum (Fig. 43-1) represent incomplete and inappropriate approaches to pain medicine. Over the long years of my practice treating a wide selection of patients, increasingly fewer of my patients receive recommendations for an exclusive regional analgesic/anesthetic approach to their pain control or rehabilitation regimen. In fact, many of my patients receive oral analgesia options with a physical rehabilitation and activity regimen, without any regional techniques as part of their therapy. These practices do not suggest that regional analgesic/anesthetic/neuromodulation regimens are not indicated in our patients. In fact, they are indicated in many patients, but they should be used with a clear indication for how they help in diagnosis or in the pain control and rehabilitation regimen in the patient with chronic pain. Their use should be incorporated into a chronic rehabilitation and cancer pain control regimen that focuses on return of function, always keeping in mind our charge as physicians to balance risk and benefit for each individual patient.

Figure 43-1. The continuum of pain medicine for patient care.

I ask that each of us use the techniques described in the following chapters on chronic pain medicine without seeking to establish positions at either polar end of the regional anesthesia technique continuum, represented by nerve block nihilism and exclusively nerve block care. Our patients will be best cared for by a mature and logical application of the rehabilitation and palliation options so well outlined in the following chapters. I particularly thank Dr. James Rathmell for providing his sound insights in the new chapters found in this section of the fourth edition of the Atlas.

The techniques outlined represent a select group of techniques in pain medicine practice. The list is not exhaustive, but rather a group of techniques that my contributors and I have found helpful in our own pain medicine practices. Most important in the use of any of these techniques is to approach each patient as an individual with unique needs, while always thinking first like a physician and holding that age-old tenet of “first do no harm” close to our decision making.